Summary Report for FSPSAs Ending During the Report Period Center: 54
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 10-01-12 and 12-31-12 Date of Report: 02-16-13 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 9.666668 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 9.666668 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.133334 $103.4700 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.016667 $0.9500 $57.0500
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 4.606164 $276.3700 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.066667 $237.6700 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 32 38 40.935745 $2046.7800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 3.857143 $289.2800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.150000 $8.3300 $55.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 6.866667 $333.0400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 1.305555 $63.3200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 11.994445 $581.7300 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.046575 $2.3300 $50.0300
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Subtotal (Total Children Is Unduplicated) 62 75 75.045629 $3996.5000 $53.2500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 5.929985 $296.5000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 16 18.396825 $919.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 82 293 230.295023 $11514.6700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.394444 $9.8600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 21 26.979367 $1348.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 32.231747 $1611.5900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 81 91.542061 $4577.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.360318 $34.0100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.066667 $51.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 4.428571 $221.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 200 213 1280.161921 $64008.0600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 34.614286 $1730.7100 $50.0000
INTR -INTR INTERPRETER 9 10 69.714285 $3485.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 17 99.209524 $6734.3500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 24 25 175.442858 $11909.0600 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.066667 $1033.3500 $500.0100
SENS -V5264 EARMOLD 3 3 2.833333 $51.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 32 34 197.401588 $13399.6300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 11.285714 $613.0400 $54.3200
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 249 592 154063.573792 $77031.7800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 8.857143 $442.8600 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 33.285715 $1664.2800 $50.0000
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Subtotal (Total Children Is Unduplicated) 265 1356 156392.077390 $202689.6100 $1.3000
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Total 1444 156476.789687 $206686.1000 $1.3200
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Number of Children (Unduplicated) With at Least One Authorization 288